Prosthetic heart valve with upper and lower skirts

ABSTRACT

A prosthetic valve structure, for use at a native atrioventricular heart valve, includes a frame, prosthetic leaflets, an upper skirt, and a lower skirt. The frame circumscribes a longitudinal axis of the structure. The leaflets are configured to facilitate upstream-to-downstream bloodflow through the structure. The upper skirt has an upstream perimeter. The lower skirt is downstream of the upper skirt, and has a downstream perimeter. The upper skirt extends away from the lower skirt, in an upstream direction and radially outward toward the upstream perimeter. The lower skirt extends away from the upper skirt, in a downstream direction and radially outward toward the downstream perimeter. A downstream portion of the frame is disposed downstream of at least part of the downstream perimeter of the lower skirt.

CROSS REFERENCES TO RELATED APPLICATIONS

The present application is a Continuation of U.S. Ser. No. 16/532,945 to HaCohen, filed Aug. 6, 2019, and entitled “PROSTHETIC HEART VALVE WITH UPPER SKIRT” (now U.S. Pat. No. 10,660,751), which is a Continuation of U.S. Ser. No. 16/388,038 to HaCohen, filed Apr. 18, 2019, and entitled “ROTATION-BASED ANCHORING OF AN IMPLANT” (now U.S. Pat. No. 10,548,726), which is a Continuation of U.S. Ser. No. 16/183,140 to HaCohen, filed Nov. 7, 2018, and entitled “FOLDING RING PROSTHETIC HEART VALVE,” which published as US 2019/0069998, and which is a Divisional of U.S. Ser. No. 15/188,507 to HaCohen, filed Jun. 21, 2016, and entitled “FOLDING RING IMPLANT FOR HEART VALVE,” which published as US 2016/0296330 (now U.S. Pat. No. 10,231,831), and which is a Continuation of U.S. Ser. No. 14/522,987 to HaCohen, filed Oct. 24, 2014, and entitled “IMPLANT FOR ROTATION-BASED ANCHORING,” which published as US 2015/0045880, and which is a Continuation of U.S. Ser. No. 12/961,721 to HaCohen, filed Dec. 7, 2010, and entitled “ROTATION-BASED ANCHORING OF AN IMPLANT,” which published as 2011/0137410 (now U.S. Pat. No. 8,870,950), which claims the benefit of U.S. Provisional Patent Application 61/283,819, entitled “FOLDABLE HINGED PROSTHETIC HEART VALVE,” to Hacohen, filed Dec. 8, 2009, which is incorporated herein by reference.

FIELD OF EMBODIMENTS OF THE INVENTION

Embodiments of the present invention relates in general to valve replacement. More specifically, embodiments of the present invention relate to replacement of an atrioventricular valve and prosthetic valve therefor.

BACKGROUND

Ischemic heart disease causes regurgitation of a heart valve by the combination of ischemic dysfunction of the papillary muscles, and the dilatation of the ventricle that is present in ischemic heart disease, with the subsequent displacement of the papillary muscles and the dilatation of the valve annulus.

Dilation of the annulus of the valve prevents the valve leaflets from fully coapting when the valve is closed. Regurgitation of blood from the ventricle into the atrium results in increased total stroke volume and decreased cardiac output, and ultimate weakening of the ventricle secondary to a volume overload and a pressure overload of the atrium.

SUMMARY OF EMBODIMENTS

In some applications of the present invention, a prosthetic heart valve structure is provided that collapses and expands by means of one or more valve pivot joints. The prosthetic valve structure is typically designated for implantation in a native atrioventricular valve site of a heart of a patient, although for some applications, the prosthetic valve structure is designated for implantation at the aortic or tricuspid valve. The prosthetic valve structure comprises an annular ring portion that is designated for placement adjacent to the ventricular surface of the native valve of the patient. This annular ring portion comprises the valve pivot joints, which facilitate collapsing of the prosthetic valve structure for transcatheter advancement of the valve toward the heart of the patient. Additionally, the annular portion of the prosthetic valve structure is coupled to a plurality of anchors which are configured to grasp the native chordae tendineae of the heart of the patient. These anchors comprise generally curved prong structures which, in an expanded state of the prosthetic valve structure, are aligned circumferentially along the annular ring portion of the prosthetic valve structure (generally perpendicular to a radius of the annular ring portion). Once the annular ring portion is positioned adjacent to the ventricular surface of the native mitral valve, the prosthetic valve structure is rotated, in order for the anchors to engage the native chordae tendineae. During the engaging, portions of the native chordae tendineae are gathered between each anchor and a respective portion of the annular ring. This engaging provides support to the prosthetic valve structure as it is positioned in and replaces the native valve. Additionally, the prosthetic valve structure comprises ventricular and atrial skirts which provide flush positioning of the prosthetic valve in the native valve.

There is therefore provided, in accordance with some applications of the present invention, apparatus for use with a prosthetic valve that is designated for implantation at a native heart valve of a patient, including:

a valve ring having a plurality of ring segments, each of the segments being hingedly coupled to at least one adjacent segment at a pivot joint,

the valve ring being configured:

-   -   to be placed adjacent to a surface of the native heart valve,         the prosthetic valve having been coupled to the valve ring,     -   in an expanded state thereof, to define a ring, all of the pivot         joints being disposed in a plane that is perpendicular to a         longitudinal axis of the ring, and     -   to be foldable from the expanded state into a shape that has a         generally circular cross-section that defines and surrounds at         least in part a central lumen, by folding the segments with         respect to each other, at the pivot joints.

For some applications, the segments of the ring are configured to become at least partially twisted due to the ring being folded from the expanded state.

For some applications, the prosthetic valve includes a trileaflet valve, and the ring has a number of ring segments that is a multiple of six.

For some applications, the ring has exactly six segments.

For some applications, the prosthetic valve includes a bileaflet valve, and the ring has a number of ring segments that is a multiple of four.

For some applications, the ring has exactly four segments.

There is further provided, in accordance with some applications of the present invention, a method for use with a prosthetic valve that is designated for implantation at a native heart valve of a patient, including:

placing in a vicinity a surface of the native heart valve, a valve ring that is coupled to the valve, while the valve ring is in a folded state thereof,

-   -   the ring having a plurality of ring segments, each of the         segments being hingedly coupled to at least one adjacent segment         at a pivot joint,     -   in the folded state thereof, the ring having a shape that has a         generally circular cross-section that defines and surrounds at         least in part a central lumen;

expanding the ring such that all of the pivot joints become disposed in a plane that is perpendicular to a longitudinal axis of the ring, by applying a force to at least some of the pivot joints; and

when the ring is in an expanded state thereof, positioning the ring adjacent to a surface of the native valve.

For some applications, applying the force to some of the pivot joints includes pushing on pivot joints that are disposed on a proximal side of the ring, while the ring is in the folded state thereof.

For some applications, the native valve includes a native mitral valve, and positioning the ring adjacent to the surface of the valve includes positioning the ring adjacent to a ventricular surface of the native mitral valve.

There is additionally provided, in accordance with some applications of the present invention, apparatus for use with a prosthetic valve that is designated for implantation at a native mitral valve of a patient, including:

an annular ring configured to be placed at a ventricular surface of the native mitral valve, the prosthetic valve having been coupled to the annular ring; and

at least one anchor disposed circumferentially with respect to the annular ring so as to define a space between the anchor and the annular ring.

For some applications, the anchor is configured to grasp a portion of native chordae tendineae of a heart of the patient by the annular ring being rotated.

For some applications, the annular ring is configured to be collapsible.

For some applications, the ring includes a plurality of ring segments, each of the segments being hingedly coupled to at least one adjacent segment at a pivot joint, and the ring is configured to be collapsed by folding the segments with respect to each other, at the pivot joints.

There is further provided, in accordance with some applications of the present invention, a method, including:

positioning an annular ring portion of a prosthetic valve structure at a ventricular surface of a native heart valve of a patient; and

grasping a portion of native chordae tendineae of a heart of the patient by rotating the annular ring portion of the prosthetic valve structure.

In some applications of the present invention, grasping the portion of the native chordae tendineae includes facilitating placing the portion of the native chordae tendineae in a space between a segment of the annular ring portion and an anchor disposed circumferentially with respect to the segment of the annular ring portion.

In some applications of the present invention, positioning the annular ring portion includes:

transcatheterally advancing the prosthetic valve structure toward the native valve of the patient in a collapsed state thereof; and

expanding the prosthetic valve structure from the collapsed state.

In some applications of the present invention, expanding the prosthetic valve structure includes pivoting a plurality of segments of the annular ring portion at respective pivot joints that couple together adjacent segments of the annular ring portion.

The present invention will be more fully understood from the following detailed description of embodiments thereof, taken together with the drawings, in which:

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a schematic illustration of an exploded view of a prosthetic heart valve, in accordance with some applications of the present invention;

FIGS. 2A-B are schematic illustrations of the prosthetic heart valve of FIG. 1 in an assembled, collapsed state, in accordance with some applications of the present invention;

FIG. 3 is a schematic illustration of the prosthetic heart valve of FIG. 1 in an assembled, expanded state, in accordance with some applications of the present invention; and

FIG. 4 is a schematic illustration of respective views of the prosthetic heart valve of FIG. 1, while anchors of the valve are anchoring the valve to chordae tendineae of a subject, in accordance with some applications of the present invention.

The following figures, mutatis mutandis, originate from U.S. Provisional Patent Application 61/283,819 to HaCohen, which was incorporated by reference into the original specification of U.S. Ser. No. 12/961,721 to HaCohen:

FIG. 5 is a schematic illustration of an exploded view of a prosthetic heart valve, in accordance with some applications of the present invention;

FIG. 6 is a schematic illustration of the prosthetic heart valve of FIG. 5 in an assembled, expanded state, in accordance with some applications of the present invention; and

FIG. 7 is a schematic illustration of the prosthetic heart valve of FIG. 5 in an assembled, collapsed state, in accordance with some applications of the present invention.

DETAILED DESCRIPTION OF THE EMBODIMENTS

Reference is now made to FIGS. 1-4, which are schematic illustrations of an expandable and collapsible prosthetic valve structure 20, in accordance with some applications of the present invention. The prosthetic valve structure is configured for implantation in and replacement of a native atrioventricular valve of a patient. Typically, the prosthetic valve structure is configured for implantation in and replacement of a native mitral valve of the patient.

The prosthetic valve structure comprises an annular valve ring 24, which comprises a plurality of curved metal segments 26 and a plurality of pivot joints 30 which facilitate the collapsing and expanding of the prosthetic valve structure. The annular valve ring is typically surrounded by a valve ring fabric sleeve 34 comprising a braided mesh of fabric, e.g., Dacron. This sleeve promotes fibrosis following implantation of the prosthetic valve structure in the native valve of the patient. The annular valve ring is coupled to a prosthetic valve that includes a plurality of valve leaflets 44. The valve leaflets are coupled to a flexible valve leaflet frame 40 (e.g., comprising nitinol, by way of illustration and not limitation), which is, in turn, coupled to a valve leaflet frame fabric 42. Typically, the valve leaflet frame fabric (e.g., a fabric comprising Dacron) is coupled to (for example, sutured to) valve ring fabric sleeve 34.

For embodiments in which the prosthetic valve is designated to replace the native mitral valve of the patient, the prosthetic valve comprises three artificial or tissue-based leaflets 44 a, 44 b, and 44 c (shown in FIG. 4), which are coupled to the inner perimeter of the annular valve ring. For example, the leaflets may include pericardium, a polymer, and/or other materials, as would be obvious to one skilled in the art.

The annular valve ring portion of the prosthetic valve structure is coupled: (1) at a first surface thereof to an upper skirt, which comprises an upper skirt fabric 38 coupled to a flexible upper skirt frame 36, and (2) at a second surface thereof to a lower skirt, which comprises a lower skirt fabric 48 coupled to a flexible lower skirt frame 46. Typically, the upper and lower frames comprise a flexible material, e.g., nitinol by way of illustration and not limitation. Typically, when the prosthetic valve structure is implanted in the expanded state, as shown in FIG. 4:

(a) the annular valve ring portion is configured to be disposed at a ventricular surface of the native valve,

(b) the upper skirt is designated to rest against an atrial portion of the native mitral valve, and

(c) the lower skirt is designated to rest against a ventricular surface of the native valve and to push radially the native leaflets of the native valve.

FIG. 1 shows components 22 of valve structure 20 in an exploded view. Each segment 26 of annular valve ring 24 is coupled at its respective ends to respective ends of adjacent segments via a hinge. For example, as shown, the hinge may include a connecting element 28 that is inserted into holes in the ends of the adjacent segments, such that the adjacent segments form a pivot joint 30. The pivot joints of the ring portion enable the entire prosthetic valve structure to pivot into a collapsed state, the collapsed state being shown in FIGS. 2A-B. Typically, the valve comprises: (a) three “upper” valve pivot joints 30U (shown in FIG. 2A) which are disposed at 120 degrees along the annular valve ring and are near the upper skirt frame 36, in the collapsed state of the valve, shown in FIG. 2A; and (b) three “lower” valve pivot joints 30L (shown in FIG. 2A) also disposed with a separation therebetween of 120 degrees, alternating with the upper valve pivot joints. The lower valve pivot joints are near the lower skirt frame 46, in the collapsed state of the valve as shown in FIG. 2A. The upper valve pivot joints are exposed at a proximal portion of the valve in the collapsed state of the valve (i.e., adjacent to an upper skirt region of the prosthetic valve structure, as shown in FIG. 2A), such that a physician is able to push on the upper valve pivot joints with a pushing tool, as described hereinbelow. Typically, when the ring is in its expanded state, all of the pivot joints are disposed in a plane that is perpendicular to longitudinal axis 10 of ring 24.

The pivot joints enable the prosthetic valve structure to collapse to form a shape having a generally circular cross-section that defines and surrounds at least in part a central lumen 50, as shown in FIGS. 2A-B. Typically, the pivot joints enable the valve to assume an outer diameter of less than 10 mm, e.g., less than 6 mm (by way of illustration and not limitation), in its collapsed state, as shown in FIG. 2A. Further typically, central lumen 50 (which is defined by ring 24 in its collapsed state) has a cross-sectional length (e.g., diameter D, shown in FIG. 2B) of between 3 mm and 5 mm, the length being measured in a plane that is perpendicular to longitudinal axis 10 of the valve (shown in FIG. 1).

Typically, when used with a trileaflet valve, ring 24 includes six segments 26, such that there are a total of six pivot joints 30 (of which three are upper pivot joints 30U, and three are lower pivot joints 30L), and such that each of the leaflets is disposed between two adjacent upper pivot joints 30U, or two adjacent lower pivot joints 30L. For some applications, the ring includes twelve (or another multiple of six) pivot joints, such that each of the leaflets of a trileaflet valve is disposed between two non-adjacent upper pivot joints 30U, or two non-adjacent lower pivot joints 30L. For some applications, ring 24 is used with a bileaflet valve. For such applications, the ring may include four, eight, or twelve segments 26, such that there are a corresponding number of pivot joints, and such that each of the leaflets is disposed between two of the upper pivot joints or two of the lower pivot joints.

Each of segments 26 of ring 24 is configured to become twisted when the ring is folded, as shown in FIG. 2A. For some applications, due to shape-memory properties of the segments, the segments facilitate the expansion of the ring, since the segments are pre-shaped in non-twisted shapes.

In the collapsed state of the valve, the valve leaflet frame, the valve leaflets, the upper skirt, and the lower skirt are also collapsed. Typically, the valve is configured such that the expansion of the ring causes each of the aforementioned portions to become expanded automatically.

In order to deploy prosthetic valve structure 20 inside the heart, the physician pushes the upper pivot joints 30U distally, using a pushing tool. The pushing of the upper pivot joints enables annular valve ring 24 to expand radially in order for the prosthetic valve structure to assume an expanded state, as shown in FIG. 3. Responsively to the expanding of the prosthetic valve structure, valve leaflet frame 40, valve leaflets 44, upper skirt frame 36, and lower skirt frame 46 also expand from their respective collapsed states.

For some applications, annular valve ring 24 is coupled to a plurality of generally curved, prong-shaped anchors 32, for example, four to eight anchors, e.g., six anchors, as shown by way of illustration and not limitation in FIG. 1. In the expanded state of valve structure 20, as shown in FIG. 3, the anchors are disposed circumferentially and in concentric alignment with the annular valve ring. As shown in FIG. 3, the anchors project from the annular valve ring through the valve ring fabric sleeve 34. As the prosthetic valve structure transitions to a collapsed state, as shown in FIG. 2A, the anchors remain alongside respective segments of the annular valve ring to which each anchor is adjacently disposed in the expanded state of the prosthetic valve structure.

During implantation of prosthetic valve structure 20, a lower portion of the prosthetic valve structure is first advanced toward the ventricular surface of the native valve. Once the distal end of the catheter is positioned in the ventricle of the patient, the physician pushes distally on the upper valve pivot joints 30 in order to (1) expose annular valve ring portion 24 and the lower skirt frame 46 and lower skirt fabric 48 from within the catheter, and (2) in conjunction, expand the annular valve ring. As the annular valve ring expands, lower skirt frame 46, valve leaflet frame 40, and valve leaflets 44 passively (i.e., automatically) expand. As the physician expands the annular valve ring, each of the anchors remain disposed circumferentially with respect to the segment of the annular valve ring to which the anchor is adjacently disposed (as shown in FIG. 3). In such a manner, a space is created between each anchor and the respective segments of the annular valve ring to which each anchor is adjacently disposed.

By pulling proximally on the catheter and the tool coupled to prosthetic valve structure 20 disposed therein, the annular valve ring is positioned adjacent to a ventricular surface of the native valve. Once the valve ring portion is positioned adjacent to the ventricular surface, the physician rotates annular valve ring 24 (e.g., by rotating 30 degrees a tool coupled thereto) about an axis that runs between the native valve from the atrium to the ventricle (which during implantation of the valve, is typically approximately aligned with longitudinal axis 10 of the valve). During this rotation, portions of native chordae tendineae 60 are grasped and placed between each anchor and the respective segment of the annular valve ring to which the anchor is adjacently disposed, as shown in FIG. 4. This grasping of the leaflets provides supplemental support to the prosthetic valve during and following implantation thereof. Alternatively or additionally, support is provided to the prosthetic valve by the upper and lower skirts, and/or by ring 24.

In conjunction with the grasping of the chordae tendineae, the prosthetic valve is secured in place. The physician then pulls the catheter proximally in order to expose upper skirt frame 36 and upper skirt fabric 38 from within the catheter. The skirt then expands over the atrial surface of the native valve in order to create a flush coupling between the prosthetic valve and the native valve.

The following description, mutatis mutandis, originates from U.S. Provisional Patent Application 61/283,819 to HaCohen, which was incorporated by reference into the original specification of U.S. Ser. No. 12/961,721 to HaCohen:

-   -   Reference is now made to FIGS. 5-7 which are schematic         illustrations of an expandable and collapsible prosthetic valve         100, in accordance with some applications of the present         invention. The prosthetic valve is configured for implantation         in and replacement of a native atrioventricular valve of a         patient. Typically, the prosthetic valve is configured for         implantation in and replacement of a native mitral valve of the         patient. The prosthetic valve comprises an annular valve ring         110 (as shown in the exploded view of FIG. 5), which comprises a         plurality of curved metal segments 112 and a plurality of pivot         joints 114 which facilitate the collapsing and expanding of the         prosthetic valve. The annular valve ring 110 is typically         surrounded by a valve ring fabric sleeve 116 comprising a         braided mesh of fabric, e.g., Dacron. This sleeve promotes         fibrosis following implantation of the prosthetic valve in the         native valve of the patient. The annular valve ring 110 is         coupled to a plurality of valve leaflets 120. The valve leaflets         are coupled to a flexible valve leaflet frame 122 (e.g.,         comprising nitinol by way of illustration and not limitation),         which is, in turn, coupled to a valve leaflet frame fabric 124.         Typically, the valve leaflet frame fabric (e.g., a fabric         comprising Dacron) is coupled to (for example, sutured to) the         valve ring fabric sleeve.     -   For embodiments in which the prosthetic valve is designated to         replace the native mitral valve of the patient, the prosthetic         valve comprises three artificial or tissue-based leaflets 120,         as shown, which are coupled to the inner perimeter of the         annular valve ring. It is to be noted that although these         leaflets are shown by way of illustration and not limitation, as         being a product of Neovasc Medical Ltd., the leaflets may         comprise any other leaflets known in the art.     -   The annular valve ring portion 110 of the prosthetic valve is         coupled: (1) at a first surface thereof to an upper skirt 140,         which comprises an upper skirt fabric 144 coupled to a flexible         upper skirt frame 142, and (2) at a second surface thereof to a         lower skirt 130, which comprises a lower skirt fabric 134         coupled to a flexible lower skirt frame 132. Typically, the         upper and lower frames comprise a flexible material, e.g.,         nitinol by way of illustration and not limitation. Typically,         when the prosthetic valve is implanted in the expanded state, as         shown in FIG. 6:     -   (a) the annular valve ring portion is configured to be disposed         at a ventricular surface of the native valve,     -   (b) the upper skirt is designated to rest against an atrial         portion of the native mitral valve, and     -   (c) the lower skirt is designated to rest against a ventricular         surface of the native valve and to push radially the native         leaflets of the native valve.     -   FIG. 5 shows the components of the valve in an exploded view.         Each segment 112 of the annular valve ring is coupled at its         respective ends to respective ends of adjacent segments via a         hinge, or a valve pivot joint 114. The pivot joints of the ring         portion enable the entire prosthetic valve to pivot into a         collapsed state, as shown in FIG. 7. Typically, the valve         comprises: (a) three “upper” valve pivot joints which are         disposed at 120 degrees along the annular valve ring and are         near the upper skirt frame, as shown in FIG. 7; and (b) three         “lower” valve pivot joints also disposed with a separation         therebetween of 120 degrees, alternating with the upper valve         pivot joints. The lower valve pivot joints are near the lower         skirt frame, as shown in FIG. 7). The upper valve pivot joints         are exposed at a proximal portion of the valve in a collapsed         state (i.e., adjacent to an upper skirt region of the prosthetic         valve, as shown in FIG. 7). The pivot joints enable the         prosthetic valve to assume a diameter of 6 mm (by way of         illustration and not limitation) in its collapsed state, as         shown in FIG. 7. In the collapsed state, the valve leaflet         frame, the valve leaflets, the upper skirt, and the lower skirt         are also collapsed.     -   In order to deploy the prosthetic valve inside the heart, the         physician distally pushes on the upper pivot joints using a         pushing tool. The pushing of the upper pivot joints enables the         annular valve ring to expand radially in order for the         prosthetic valve to assume an expanded state, as shown in         FIG. 6. Responsively to the expanding of the prosthetic valve,         the valve leaflet frame, the valve leaflets, the upper skirt,         and the lower skirt also expand from their respective collapsed         states.     -   The annular valve ring is coupled to a plurality of generally         curved, prong-shaped anchors 150, e.g., 6 as shown by way of         illustration and not limitation in FIG. 5. In an expanded state,         as shown in FIG. 6, the anchors are disposed circumferentially         and in concentric alignment with the annular valve ring. As         shown in FIG. 6, the anchors project from the annular valve ring         through the valve ring fabric sleeve. As the prosthetic valve         transitions to a collapsed state, as shown in FIG. 7, the         anchors remain alongside respective segments of the annular         valve ring to which each anchor is adjacently disposed in the         expanded state of the prosthetic valve.     -   During implantation of the prosthetic valve, a lower portion of         the prosthetic valve is first advanced toward the ventricular         surface of the native valve. Once the distal end of the catheter         is positioned in the ventricle of the patient, the physician         pushes distally on the upper valve pivot joints in order to (1)         expose the annular valve ring portion and the lower skirt from         within the catheter, and (2) in conjunction, expand the annular         valve ring. As the annular valve ring expands, the lower skirt,         the valve leaflet frame, and the valve leaflets passively         expand. As the physician expands the annular valve ring, each of         the anchors remain disposed circumferentially with respect to         the segment of the annular valve ring to which the anchor is         adjacently disposed (as shown in FIG. 6). In such a manner a         space is created between each anchor and the respective segments         of the annular valve ring to which each anchor is adjacently         disposed.     -   By pulling proximally on the catheter and the tool coupled to         the prosthetic valve disposed therein, the annular valve ring is         positioned adjacent to a ventricular surface of the native         valve. Once the valve ring portion is positioned adjacent to the         ventricular surface, the physician rotates the annular valve         ring (e.g., by rotating 30 degrees a tool coupled thereto) about         an axis that runs between the native valve from the atrium to         the ventricle. During this rotation, portions of the native         chordeae tendineae are grasped and placed between each anchor         and the respective segment of the annular valve ring to which         the anchor is adjacently disposed. This grasping of the leaflets         provides supplemental support to the prosthetic valve during and         following implantation thereof.     -   In conjunction with the grasping of the chordeae tendineae, the         prosthetic valve is secured in place. The physician then pulls         the catheter proximally in order to expose the upper skirt from         within the catheter. The skirt then expands over the atrial         surface of the native valve in order to create a flush coupling         between the prosthetic valve and the native valve.

It will be appreciated by persons skilled in the art that the present invention is not limited to what has been particularly shown and described hereinabove. Rather, the scope of the present invention includes both combinations and subcombinations of the various features described hereinabove, as well as variations and modifications thereof that are not in the prior art, which would occur to persons skilled in the art upon reading the foregoing description. 

The invention claimed is:
 1. Apparatus for use at a native atrioventricular valve of a heart of a subject, the apparatus comprising a prosthetic valve structure that comprises: a leaflet frame, circumscribing a longitudinal axis of the prosthetic valve structure; prosthetic leaflets, coupled to the leaflet frame, and configured to facilitate upstream-to-downstream bloodflow longitudinally through the prosthetic valve structure; an upper skirt, having an upstream perimeter; a lower skirt, downstream of the upper skirt, and having a downstream perimeter; and downstream of the upper skirt and upstream of the lower skirt, a plurality of metal segments forming a waist of the prosthetic valve structure, wherein: (1) the upper skirt: extends away from the lower skirt, in an upstream direction and radially outward toward the upstream perimeter, and is configured to rest against an atrial surface of the native atrioventricular valve, (2) the lower skirt: (a) extends away from the upper skirt, in a downstream direction and radially outward toward the downstream perimeter, (b) comprises a lower skirt frame and fabric coupled to the lower skirt frame, wherein the lower skirt frame: (i) is shaped to define a plurality of lower-skirt petals, each petal having an ascending portion and a descending portion, such that the lower skirt frame defines a plurality of ascending portions and descending portions, each of the lower-skirt petals extending radially outward and in a downstream direction from the upper skirt, adjacent ascending and descending portions forming respective upstream peaks of the lower skirt frame, each upstream peak being disposed downstream of the waist, and (ii) has an outer edge that defines a path circumferentially around the longitudinal axis along which the plurality of ascending portions and descending portions of the lower skirt frame are disposed, wherein the plurality of ascending portions and descending portions of the lower skirt frame are disposed radially outward and distanced from the leaflet frame, and (c) is configured to rest against a ventricular surface of the native atrioventricular valve, and (3) a downstream portion of the leaflet frame is disposed downstream of at least part of the downstream perimeter of the lower skirt.
 2. The apparatus according to claim 1, wherein the upper skirt comprises an upper skirt frame, and fabric coupled to the upper skirt frame.
 3. The apparatus according to claim 2, wherein the outer edge of lower skirt frame defines a wavy path circumferentially around the longitudinal axis, and that is disposed radially outward from the leaflet frame.
 4. The apparatus according to claim 3, wherein the upper skirt frame has an outer edge that defines a wavy path circumferentially around the longitudinal axis, and that is disposed radially outward from the leaflet frame.
 5. The apparatus according to claim 4, wherein: the wavy path of the outer edge of the upper skirt frame defines alternating upper-skirt crests and upper-skirt dips, the upper-skirt crests being further from the longitudinal axis than the upper-skirt dips, the wavy path of the outer edge of the lower skirt frame defines alternating lower-skirt crests and lower-skirt dips, the lower-skirt crests being further from the longitudinal axis than the lower-skirt dips, and the alternating of the wavy path of the outer edge of the lower skirt frame is out of phase with the alternating of the wavy path of the outer edge of the upper skirt frame.
 6. The apparatus according to claim 3, wherein the wavy path has a wavelength, and wherein the prosthetic valve structure is collapsible into a collapsed state for transcatheter delivery to the heart, collapsing of the prosthetic valve structure into the collapsed state reducing the wavelength of the wavy path.
 7. The apparatus according to claim 2, wherein the upper skirt frame and the lower skirt frame both comprise Nitinol.
 8. The apparatus according to claim 1, wherein the lower skirt extends from the leaflet frame in a manner that defines a space that circumscribes the leaflet frame and is disposed between the leaflet frame and the lower skirt.
 9. The apparatus according to claim 1, wherein the upstream perimeter of the upper skirt is disposed upstream of the leaflet frame.
 10. The apparatus according to claim 1, wherein the upper skirt is shaped to define a plurality of upper-skirt petals, each of the upper-skirt petals extending radially outward and in an upstream direction from lower skirt.
 11. The apparatus according to claim 10, wherein the upper-skirt petals are circumferentially out of phase with respect to the lower-skirt petals.
 12. The apparatus according to claim 1, wherein each of the leaflets is disposed within, and secured to, the downstream portion of the leaflet frame.
 13. The apparatus according to claim 12, wherein: the downstream portion of the leaflet frame comprises a plurality of posts, and at each post of the plurality of posts, a part of one leaflet of the plurality of leaflets converges with a part of another leaflet of the plurality of leaflets, and the part of the one leaflet and the part of the other leaflet are secured to the post.
 14. The apparatus according to claim 1, further comprising a plurality of curved prong-shaped anchors distributed circumferentially around the longitudinal axis.
 15. The apparatus according to claim 14, wherein all of the curved prong-shaped anchors are entirely disposed downstream of the upper skirt.
 16. The apparatus according to claim 14, wherein: the plurality of metal segments are joined at a respective plurality of joints, the joints facilitating (i) collapsing of the prosthetic valve structure into a collapsed state for transcatheter delivery to the heart, and (ii) expanding of the prosthetic valve structure into a deployed state within the heart, and each of the curved prong-shaped anchors projects from a respective one of the plurality of joints.
 17. The apparatus according to claim 16, wherein: at each of the plurality of joints from which a respective curved prong-shaped anchor of the plurality of curved prong-shaped anchors projects, a first metal segment of the plurality of segments is joined to a second metal segment of the plurality of segments, and the respective curved prong-shaped anchor is shorter than the first metal segment and is shorter than the second metal segment.
 18. The apparatus according to claim 1, further comprising a leaflet-frame fabric that is coupled to the leaflet frame.
 19. The apparatus according to claim 1, wherein the leaflet frame comprises Nitinol.
 20. The apparatus according to claim 1, wherein the prosthetic valve structure is collapsible into a collapsed state for transcatheter delivery to the heart.
 21. Apparatus for use at a native atrioventricular valve of a heart of a subject, the apparatus comprising a prosthetic valve structure that comprises: a leaflet frame, circumscribing a longitudinal axis of the prosthetic valve structure; prosthetic leaflets, coupled to the leaflet frame, and configured to facilitate upstream-to-downstream bloodflow longitudinally through the prosthetic valve structure; an upper skirt, having an upstream perimeter; and a lower skirt, downstream of the upper skirt, and having a downstream perimeter, wherein: (1) the upper skirt: extends away from the lower skirt, in an upstream direction and radially outward toward the upstream perimeter, and is configured to rest against an atrial surface of the native atrioventricular valve, (2) the lower skirt: extends away from the upper skirt, in a downstream direction and radially outward toward the downstream perimeter, and is configured to rest against a ventricular surface of the native atrioventricular valve, and (3) a downstream portion of the leaflet frame is disposed downstream of at least part of the downstream perimeter of the lower skirt, and wherein: the prosthetic valve structure defines a narrowed waist on a plane that is perpendicular to the longitudinal axis, longitudinally between the upper skirt and the lower skirt; the prosthetic valve structure further comprises joints, distributed circumferentially around the longitudinal axis on the plane; and each of the joints comprises a respective connecting element that connects metal segments of the prosthetic valve structure by being inserted into a respective hole of the prosthetic valve structure.
 22. Apparatus for use at a native atrioventricular valve of a heart of a subject, the apparatus comprising a prosthetic valve structure that comprises: a leaflet frame, circumscribing a longitudinal axis of the prosthetic valve structure; prosthetic leaflets, coupled to the leaflet frame, and configured to facilitate upstream-to-downstream bloodflow longitudinally through the prosthetic valve structure; an upper skirt, having an upstream perimeter; a lower skirt, downstream of the upper skirt, and having a downstream perimeter; and downstream of the upper skirt and upstream of the lower skirt, a plurality of metal segments forming a waist of the prosthetic valve structure, wherein: (1) the upper skirt: extends away from the lower skirt, in an upstream direction and radially outward toward the upstream perimeter, and is configured to rest against an atrial surface of the native atrioventricular valve, (2) the lower skirt: (a) extends away from the upper skirt, in a downstream direction and radially outward toward the downstream perimeter, (b) comprises a lower skirt frame and fabric coupled to the lower skirt frame, wherein the lower skirt frame: (i) is shaped to define a plurality of lower-skirt petals, each petal having an ascending portion and a descending portion such that the lower skirt frame defines a plurality of ascending portions and descending portions, each of the lower-skirt petals extending radially outward and in a downstream direction from the upper skirt, adjacent ascending and descending portions forming respective upstream peaks of the lower skirt frame, each upstream peak being disposed downstream of the waist, and (ii) has an outer edge that defines a path circumferentially around the longitudinal axis along which the plurality of ascending portions and descending portions of the lower skirt frame are disposed, wherein the plurality of ascending portions and descending portions of the lower skirt frame are disposed radially outward and distanced from the leaflet frame, and (c) is configured to rest against a ventricular surface of the native atrioventricular valve, and (3) a downstream portion of each of the prosthetic leaflets is disposed downstream of at least part of the downstream perimeter of the lower skirt.
 23. The apparatus according to claim 22, wherein the upper skirt comprises an upper skirt frame, and fabric coupled to the upper skirt frame.
 24. The apparatus according to claim 23, wherein the outer edge of the lower skirt frame defines a wavy path circumferentially around the longitudinal axis, and that is disposed radially outward from the leaflet frame.
 25. The apparatus according to claim 22, wherein the lower skirt extends from the leaflet frame in a manner that defines a space that circumscribes the leaflet frame and is disposed between the leaflet frame and the lower skirt.
 26. The apparatus according to claim 22, wherein the upstream perimeter of the upper skirt is disposed upstream of the leaflet frame.
 27. The apparatus according to claim 22, further comprising a plurality of curved prong-shaped anchors distributed circumferentially around the longitudinal axis.
 28. The apparatus according to claim 27, wherein all of the curved prong-shaped anchors are entirely disposed downstream of the upper skirt.
 29. Apparatus for use at a native atrioventricular valve of a heart of a subject, the apparatus comprising a prosthetic valve structure that comprises: a leaflet frame, circumscribing a longitudinal axis of the prosthetic valve structure; prosthetic leaflets, coupled to the leaflet frame, and configured to facilitate upstream-to-downstream bloodflow longitudinally through the prosthetic valve structure; an upper skirt, having an upstream perimeter; and a lower skirt, downstream of the upper skirt, and having a downstream perimeter, wherein: (1) the upper skirt: extends away from the lower skirt, in an upstream direction and radially outward toward the upstream perimeter, and is configured to rest against an atrial surface of the native atrioventricular valve, (2) the lower skirt: extends away from the upper skirt, in a downstream direction and radially outward toward the downstream perimeter, and is configured to rest against a ventricular surface of the native atrioventricular valve, and (3) a downstream portion of each of the prosthetic leaflets is disposed downstream of at least part of the downstream perimeter of the lower skirt, and wherein: the prosthetic valve structure defines a narrowed waist on a plane that is perpendicular to the longitudinal axis, longitudinally between the upper skirt and the lower skirt; the prosthetic valve structure further comprises joints, distributed circumferentially around the longitudinal axis on the plane; and each of the joints comprises a respective connecting element that connects metal segments of the prosthetic valve structure by being inserted into a respective hole of the prosthetic valve structure.
 30. Apparatus for use at a native atrioventricular valve of a heart of a subject, the apparatus comprising a prosthetic valve structure that comprises: a leaflet frame, circumscribing a longitudinal axis of the prosthetic valve structure; prosthetic leaflets, coupled to the leaflet frame, and configured to facilitate upstream-to-downstream bloodflow longitudinally through the prosthetic valve structure; an upper skirt, having an upstream perimeter; a lower skirt, downstream of the upper skirt, and having a downstream perimeter that shapes the lower skirt to define a plurality of lower-skirt petals, each of the lower-skirt petals extending radially outward and in a downstream direction from the upper skirt; and downstream of the upper skirt and upstream of the lower skirt, a plurality of metal segments forming a waist of the prosthetic valve structure, wherein: (1) the upper skirt: extends away from the lower skirt, in an upstream direction and radially outward toward the upstream perimeter, and is configured to rest against an atrial surface of the native atrioventricular valve, (2) the lower skirt: (a) extends away from the upper skirt, in a downstream direction and radially outward toward the downstream perimeter, (b) comprises a lower skirt frame and fabric coupled to the lower skirt frame, wherein the lower skirt frame: (i) is shaped to define the plurality of lower-skirt petals, each petal having an ascending portion and a descending portion such that the lower skirt frame defines a plurality of ascending portions and descending portions, adjacent ascending and descending portions forming respective upstream peaks of the lower skirt frame, each upstream peak being disposed downstream of the waist, and (ii) has an outer edge that defines a path circumferentially around the longitudinal axis along which the plurality of ascending portions and descending portions of the lower skirt frame are disposed, wherein the plurality of ascending portions and descending portions of the lower skirt frame are disposed radially outward and distanced from the leaflet frame, and (c) is configured to rest against a ventricular surface of the native atrioventricular valve, and (3) a downstream portion of the leaflet frame is disposed downstream of at least part of the downstream perimeter of the lower skirt.
 31. The apparatus according to claim 30, wherein the upper skirt comprises an upper skirt frame, and fabric coupled to the upper skirt frame.
 32. The apparatus according to claim 31, wherein the outer edge of the lower skirt frame is disposed at the downstream perimeter, and defines a wavy path circumferentially around the longitudinal axis, and that is disposed radially outward from the leaflet frame.
 33. The apparatus according to claim 32, wherein the upper skirt frame has an outer edge that defines a wavy path circumferentially around the longitudinal axis, and that is disposed radially outward from the leaflet frame.
 34. The apparatus according to claim 33, wherein: the wavy path of the outer edge of the upper skirt frame defines alternating upper-skirt crests and upper-skirt dips, the upper-skirt crests being further from the longitudinal axis than the upper-skirt dips, the wavy path of the outer edge of the lower skirt frame defines alternating lower-skirt crests and lower-skirt dips, the lower-skirt crests being further from the longitudinal axis than the lower-skirt dips, and the alternating of the wavy path of the outer edge of the lower skirt frame is out of phase with the alternating of the wavy path of the outer edge of the upper skirt frame.
 35. The apparatus according to claim 30, wherein the upstream perimeter of the upper skirt is disposed upstream of the leaflet frame.
 36. The apparatus according to claim 30, wherein the upper skirt is shaped to define a plurality of upper-skirt petals, each of the upper-skirt petals extending radially outward and in an upstream direction from lower skirt.
 37. The apparatus according to claim 36, wherein the upper-skirt petals are circumferentially out of phase with respect to the lower-skirt petals.
 38. Apparatus for use at a native atrioventricular valve of a heart of a subject, the apparatus comprising a prosthetic valve structure that comprises: a leaflet frame, circumscribing a longitudinal axis of the prosthetic valve structure; prosthetic leaflets, coupled to the leaflet frame, and configured to facilitate upstream-to-downstream bloodflow longitudinally through the prosthetic valve structure; an upper skirt, having an upstream perimeter; a lower skirt, downstream of the upper skirt, and having a downstream perimeter; and downstream of the upper skirt and upstream of the lower skirt, a plurality of metal segments forming a waist of the prosthetic valve structure, wherein: (1) the upper skirt: extends away from the lower skirt, in an upstream direction and radially outward toward the upstream perimeter, and is configured to rest against an atrial surface of the native atrioventricular valve, (2) the lower skirt: (a) extends away from the upper skirt, in a downstream direction and radially outward toward the downstream perimeter, (b) comprises a lower skirt frame and fabric coupled to the lower skirt frame, wherein the lower skirt frame: (i) is shaped to define a plurality of ascending portions and descending portions, adjacent ascending and descending portions forming respective upstream peaks of the lower skirt frame, each upstream peak being disposed downstream of the waist, (ii) has an outer edge that defines a path circumferentially around the longitudinal axis along which the plurality of ascending portions and descending portions of the lower skirt frame are disposed, wherein the plurality of ascending portions and descending portions of the lower skirt frame are disposed radially outward and distanced from the waist of the prosthetic valve structure, and (c) is configured to rest against a ventricular surface of the native atrioventricular valve, and (3) a downstream portion of the leaflet frame is disposed downstream of at least part of the downstream perimeter of the lower skirt. 